Personal method of suturing the blad der, which has met with uniform success in the eight cases of suprapubic cystot omy in which it has been employed, as well as in experiments upon animals. The method consists of the following steps: First, the mucosa and muscularis are separated from each other for a dis tance of half a centimetre to two centi metres from either edge of the incision. This flap of mucous membrane is resected, and the mucous edges sutured with cat gut. Second, the muscular flap is placed over the line of suturing in the mucous membrane and fixed there by three lines of sutures: a U-shaped suture which unites the base of the flap with the edges of the bladder-wound, a suture which fixes the free edge of the flap, and a third suture which unites the mucous-mem brane portion of the flap with the blad der-wall. By this means the incisions in the mucosa and muscularis are kept from directly overlying each other, and uri nary infiltration thus obviated. T. Jon nesco (Gaz. des 116p., No. 2, '99).
The suprapubic operation, even though the stone be large, is not to be compared to the vaginal route when this canal is fully developed, as in the adult female, especially in eases of married women. In the suprapubic operation there is no natural drainage. The urine must be re tained in a bladder already inflamed, where it acts as a still further irritant, or must drain out through the abdominal wound at the risk of urinary infiltration and of setting up inflammatory action in the site of the wound. In the vesieo vaginal route the urine flows out con stantly at first, allowing no new irrita tion of the inflamed lining of the bladder and permitting a free and ready escape of urine, pus, mucus, and any remaining portion of the calculus. J. Happel (Phila. Med. Jour., Apr. 29, '99).
Vesical Tuberculosis.
The majority of cases of tuberculosis of the bladder occur before the fortieth year. It is usually secondary to de posits elsewhere. In a small propor tion of cases the disease seems to be primary in the bladder. Many of the secondary cases follow tuberculosis of the kidney or an ascending infection from the epididymis. More rarely there is a direct extension from the prostate or seminal vesicles.
Symptoms.—The symptoms of tuber culosis of the bladder develop insidiously and are so slight in the early stages that advice is rarely sought until the disease has lasted for some time. The earliest manifestation observed by the patient in most cases is increased frequency of urination. Pain usually follows sooner or later. It is mild in some cases and severe in others, depending upon the location of the disease. Deposits at the neck of the bladder always give rise to considerable pain. Pus and blood are invariably present in the urine, the quan tity varying in different cases, and at different times in the same ease. These are merely the result of the ulcerating process, and not of the tuberculosis per se. Cystitis develops sooner or later, when the symptoms are much more pro nounced, the pain, frequency of urina tion, and tenesmus all being much in creased.
There is nothing peculiar about the symptomatology of vesical tuberculosis. The diagnosis must rest upon the detec tion of tubercle bacilli in the urine of a person who has the symptoms of chronic cystitis. If bacilli are found, how ever, we are unable, in many cases, to determine whether they emanate from a focus of disease in the kidney or in the bladder. -On the other hand, bacilli are not detected in some cases of genuine vesieal tuberculosis. It is quite possible to have tuberculosis of the kidney in con junction with a non-tubercular cystitis. The diagnosis will usually be made first by excluding the common causes of cys titis—namely: gonorrhoea, vesieal calcu lus, stricture of the urethra, and hyper trophied prostate—by the usual meth ods of detecting these conditions; and, secondly, by meeting with the evidences of marked cystitis with tubercle bacilli in the urine and without any symptoms referable to the kidney. A tubercular family history or the presence of a tuber cular lesion elsewhere in the patient would point to a similar condition in the bladder. In looking for the presence of tubercle bacilli repeated examinations should be made before deciding that they are absent. Finally cystoscopical exam ination may yield valuable evidence, either by showing the presence of a tuberculous process or by establishing the absence of such a condition. If no cause can be found in the bladder it would be well to catheterize the ureters separately in order to locate the seat of the disease.
The treatment in the early stages is almost purely constitutional. The pa tient should be surrounded by the most favorable hygienic conditions; if it is possible to build the patient up by forced feeding, suitable climate, etc., the disease may be arrested and healing follow. The urine should be kept as healthy as pos sible by the administration of a urinary antiseptic and by the use of milk and water in liberal quantities. In the pres ence of a pronounced cystitis, the proper treatment for this condition should be instituted. Among the drugs employed in the local treatment, iodoform occupies a prominent place. The introduction of a small quantity of a 10-per-cent. mixt ure in sterilized olive-oil or glycerin every few days should be tried. The bladder should first be thoroughly irri gated in order to prepare for the iodo form, and, if any evidences of irritation follow the treatment, it should not be repeated until this has subsided. Irri gations of biehloride of mercury, begin ning with 1 part in 5000, is highly ex tolled by Guyon. It does not seem cer tain, however, that this could have any specific effect on the tuberculous process, and it is a question whether this treat ment does more than to relieve the ac companying cystitis. For severe pain, tenesmus, and frequency of urination, suppositories of opium and belladonna may be necessary.